Title Page
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Return to Work
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Conducted on:
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Conducted by:
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Colleague Name:
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Job Title:
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Department:
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Employee Number:
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Name of Line Manager:
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Date of meeting:
Current sickness absence (to be completed by your line manager with you)
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Date of absence:
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Number of days absence:
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Confirm reason for absence:
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Did you seek medical advice?
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Fit note received?
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Number of days that will be paid?
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Number of days that will be unpaid? (Refer to sick pay policy if necessary to explain why)
In order to establish how you are and if there are any underlying issues or concerns with regard to your health, the following will be discussed:
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How are you feeling now that you have come back to work?
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What medical advice have you received?
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Are you still undergoing medical treatment? If so, What is it? Are there any potential side effects?
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Is there anything else that you feel may be contributing or has contributed to your sickness absence?
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What additional support do you need from me or the company? E.g a referral to Occupational Health/employee support programme, a desk assessment, adjustments to your equipment or working area,
Previous sickness absence (to be completed by your line manager if applicable)
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Previous Absences - List each separate occasion, with number of days and reason.
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Total number of days absent in the last 6 months:
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Total number of days absent in the last 12 months :
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Are you aware of the absence reporting procedures?
Sickness Triggers
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6 month sickness trigger -
3 separate incidents/spells of sickness
A total of 10 working days or more
12 month sickness trigger -
5 separate incidents/spells of sickness
A total of 15 working days or more -
Sickness trigger hit?
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Please detail if the sickness has been triggered:
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Convert into sickness absence percentage:
Total number of sick days (past 26 weeks)
Total number of days scheduled to work (number of days per week x 26)
Total number of sick days divided by total number of days scheduled to work
Multiplied by 100 -
Sickness absence policy % (Using calculations above)
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Action Plan (Agreed adjustments, Review dates and Comments)
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Employee Signature:
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Line Manager Signature:
